
<!DOCTYPE html>
<html lang="en">
<head>
    <meta charset="UTF-8">
    <title>项目申请</title>
    <link rel="stylesheet" href="/Public/Home/extend/css/head.css">
    <link rel="stylesheet" href="/Public/Home/extend/css/foot.css">
    <link rel="stylesheet" href="/Public/Home/extend/css/demand.css">
    <link rel="stylesheet" href="/Public/Home/extend/css/project.css">
    <link rel="stylesheet" href="/Public/Home/extend/css/style.css">
    </head>
<body style="background: #f6f6f6">

<form class="form form-horizontal" id="form-add" enctype="multipart/form-data" novalidate="novalidate">
    <div class="project_content">
    <div class="demand_div">
        <div class="demand_div1">
            <img src="/Public/Home/extend/img/1.jpg" alt="">
            <span>项目申请</span>
        </div>
    </div>
    <div class="project_div">
      <div>
          <span>项目申请选择：</span>

          <div style="margin: 0" class="c-dropdown js-dropdown">
              <input name="p_id" id="Framework" class="js-dropdown__input" value="" type="hidden">
              <span class="c-button c-button--dropdown js-dropdown__current">请选择</span>
              <ul class="c-dropdown__list">
                  <li class="c-dropdown__item" data-dropdown-value="6">道路占用挖掘审核</li><li class="c-dropdown__item" data-dropdown-value="5">道路新增出入口审核</li><li class="c-dropdown__item" data-dropdown-value="4">交通安全设施竣工验收</li><li class="c-dropdown__item" data-dropdown-value="3">交通安全设施设计的审核</li><li class="c-dropdown__item" data-dropdown-value="2">公交站点的设置和审核</li><li class="c-dropdown__item" data-dropdown-value="1">大型项目交通影响评价</li>              </ul>
          </div>

      </div>
        <div>
            <span>附件上传：</span>
            <div style="margin: 0;" id="form1" class="uploader white">
                <input class="filename" name="path" placeholder="请选择要上传的文件" readonly="" type="text"><span style="display: inline-block;color:#d0d0d0;margin-left: -85px;background:#063892;padding: 10px 10px;border-radius: 10px;margin-top: 5px ">选择上传</span>

                <input name="upfile" type="file">
            </div>

            <span>参考资料下载：<a style="color: #063892;text-decoration: none" href="file/授权类特许产品.rar">许可证（样本）.PDF</a>
            </span>
        </div>
        <div class="check">
            <span>材料寄送：</span>
            <lable>
                <i class="input_style radio_bg"><input checked="checked" name="is_deliver" value="2" class="valid" type="radio"></i>
                否
            </lable>
            <lable>
                <i class="input_style radio_bg radio_bg_check"><input name="is_deliver" value="1" class="valid" type="radio"></i>
                是
            </lable>
        </div>
        <div class="text">
            <span>快递单号：</span>
            <input placeholder="请输入快递单号" name="tracking_no" value="" type="tel">
        </div>
    </div>
    <div class="project_div1">
        <div class="div1">主审单位</div>
        <div>
            <div>
                <span>部门职务：</span>
                <input placeholder="请输入部门职务" name="depart_name" value="" type="text">
            </div>
            <div style="margin-left: 33px">
                <span>联系人：</span>
                <input placeholder="请输入联系人" name="contact" value="" type="text">
            </div>
            <div>
                <span>电话号码：</span>
                <input placeholder="请输入电话号码" name="contact_phone" value="" type="tel">
            </div>
            <div class="form">
                <span>邮寄地址：</span>
                <select name="contact_p" id="selProvincesContact" onchange="region.changed(this, 2, 'selCitiesContact')">
                    <option value="">选择省</option>
                    <option value="110000">北京</option><option value="120000">天津</option><option value="130000">河北省</option><option value="140000">山西省</option><option value="150000">内蒙古自治区</option><option value="210000">辽宁省</option><option value="220000">吉林省</option><option value="230000">黑龙江省</option><option value="310000">上海</option><option value="320000">江苏省</option><option value="330000">浙江省</option><option value="340000">安徽省</option><option value="350000">福建省</option><option value="360000">江西省</option><option value="370000">山东省</option><option value="410000">河南省</option><option value="420000">湖北省</option><option value="430000">湖南省</option><option value="440000">广东省</option><option value="450000">广西壮族自治区</option><option value="460000">海南省</option><option value="500000">重庆</option><option value="510000">四川省</option><option value="520000">贵州省</option><option value="530000">云南省</option><option value="540000">西藏自治区</option><option value="610000">陕西省</option><option value="620000">甘肃省</option><option value="630000">青海省</option><option value="640000">宁夏回族自治区</option><option value="650000">新疆维吾尔自治区</option><option value="710000">台湾</option><option value="810000">香港特别行政区</option><option value="820000">澳门特别行政区</option><option value="900000">钓鱼岛</option>                </select>
                <select name="contact_c" id="selCitiesContact" onchange="region.changed(this, 3, 'selDistrictsContact')">
                    <option value="">选择市</option>
                </select>
                <select name="contact_d" id="selDistrictsContact">
                    <option value="">选择区</option>
                </select>
                <input style="margin-left: 30px" name="contact_address" placeholder="具体收件地址" type="text">
            </div>
        </div>
    </div>
    <div class="project_div2">
        <div class="check1 ">
            <span>现场勘测:</span>
            <lable>
                <i class="input_style radio_bg"><input name="need_survey" value="2" checked="" class="valid" type="radio"></i>
                不需要
            </lable>
            <lable>
                <i class="input_style radio_bg radio_bg_check"><input name="need_survey" value="1" class="valid" type="radio"></i>
                需要
            </lable>
        </div>
        <div class="text1">
            <div style="margin-left:30px ">
                <span>时间:</span>
                <input placeholder="请选择时间" value="" name="survey_start_time" onfocus="WdatePicker({ minDate:'%y-%M-%d',dateFmt:'yyyy-MM-dd' })" id="logmin" class=" Wdate" style="width:160px;" type="text">
                -<input placeholder="请选择时间" value="" name="survey_end_time" onfocus="WdatePicker({ minDate:'#F{$dp.$D(\'logmin\')}',dateFmt:'yyyy-MM-dd' })" id="logmax" class=" Wdate" style="width:160px;" type="text">
            </div>
            <div style="margin-left:30px ">
                <span>地点:</span>
                <select name="survey_p" id="selProvincesSurvey" onchange="region.changed(this, 2, 'selCitiesSurvey')">
                    <option value="">选择省</option>
                    <option value="110000">北京</option><option value="120000">天津</option><option value="130000">河北省</option><option value="140000">山西省</option><option value="150000">内蒙古自治区</option><option value="210000">辽宁省</option><option value="220000">吉林省</option><option value="230000">黑龙江省</option><option value="310000">上海</option><option value="320000">江苏省</option><option value="330000">浙江省</option><option value="340000">安徽省</option><option value="350000">福建省</option><option value="360000">江西省</option><option value="370000">山东省</option><option value="410000">河南省</option><option value="420000">湖北省</option><option value="430000">湖南省</option><option value="440000">广东省</option><option value="450000">广西壮族自治区</option><option value="460000">海南省</option><option value="500000">重庆</option><option value="510000">四川省</option><option value="520000">贵州省</option><option value="530000">云南省</option><option value="540000">西藏自治区</option><option value="610000">陕西省</option><option value="620000">甘肃省</option><option value="630000">青海省</option><option value="640000">宁夏回族自治区</option><option value="650000">新疆维吾尔自治区</option><option value="710000">台湾</option><option value="810000">香港特别行政区</option><option value="820000">澳门特别行政区</option><option value="900000">钓鱼岛</option>                </select>
                <select name="survey_c" id="selCitiesSurvey" onchange="region.changed(this, 3, 'selDistrictsSurvey')">
                    <option value="">选择市</option>
                </select>
                <select name="survey_d" id="selDistrictsSurvey">
                    <option value="">选择区</option>
                </select>
                <input style="margin-left: 30px" name="survey_address" placeholder="具体地址" type="text">
            </div>
            <div style="margin-left:15px ">
                <span>联系人:</span>
                <input placeholder="请输入联系人" name="survey_contact" type="text">
            </div>
            <div>
                <span>注意事项:</span>
                <input name="survey_attention" placeholder="请输入注意事项" type="text">
            </div>
        </div>

        <div class="check2">
            <span>审批表格<br>是否寄送:</span>
            <lable>
                <i class="input_style radio_bg"><input name="need_deliver" value="2" checked="" class="valid" type="radio"></i>
                否
            </lable>
            <lable>
                <i class="input_style radio_bg radio_bg_check"><input name="need_deliver" value="1" class="valid" type="radio"></i>
                是
            </lable>
        </div>
        <div class="text">
            <div style="margin-left: 15px">
                <span>收件人:</span>
                <input placeholder="请输入收件人姓名 " name="receiver_name" type="text">
            </div>
            <div>
                <span>收件地址:</span>
                <select name="receiver_p" id="selProvincesReceiver" onchange="region.changed(this, 2, 'selCitiesReceiver')">
                    <option value="">选择省</option>
                    <option value="110000">北京</option><option value="120000">天津</option><option value="130000">河北省</option><option value="140000">山西省</option><option value="150000">内蒙古自治区</option><option value="210000">辽宁省</option><option value="220000">吉林省</option><option value="230000">黑龙江省</option><option value="310000">上海</option><option value="320000">江苏省</option><option value="330000">浙江省</option><option value="340000">安徽省</option><option value="350000">福建省</option><option value="360000">江西省</option><option value="370000">山东省</option><option value="410000">河南省</option><option value="420000">湖北省</option><option value="430000">湖南省</option><option value="440000">广东省</option><option value="450000">广西壮族自治区</option><option value="460000">海南省</option><option value="500000">重庆</option><option value="510000">四川省</option><option value="520000">贵州省</option><option value="530000">云南省</option><option value="540000">西藏自治区</option><option value="610000">陕西省</option><option value="620000">甘肃省</option><option value="630000">青海省</option><option value="640000">宁夏回族自治区</option><option value="650000">新疆维吾尔自治区</option><option value="710000">台湾</option><option value="810000">香港特别行政区</option><option value="820000">澳门特别行政区</option><option value="900000">钓鱼岛</option>                </select>
                <select name="receiver_c" id="selCitiesReceiver" onchange="region.changed(this, 3, 'selDistrictsReceiver')">
                    <option value="">选择市</option>
                </select>
                <select name="receiver_d" id="selDistrictsReceiver">
                    <option value="">选择区</option>
                </select>
                <input style="margin-left: 30px" placeholder="具体收件地址" name="receiver_address" type="text">

            </div>
            <div>
                <span>联系方式:</span>
                <input placeholder="请输入联系方式" value="" name="receiver_phone" type="tel">
            </div>
        </div>

        <div style="margin-left: 15px">
            <span>申请人:</span>
            <input placeholder="请输入申请人姓名" value="" name="submitter" type="text">
        </div>
        <div>
            <span>申请单位:</span>
            <input placeholder="请输入申请单位全称" value="" name="submitter_company" type="text">
        </div>
        <div>
            <span>手机号码:</span>
            <input placeholder="请输入手机号码" value="" name="validate_phone" id="validate_phone" type="text">
        </div>
        <div>
            <span>验证码：</span>
            <input placeholder="请输入验证码" name="validate_code" type="text">
            <!--<i style="color: red">*验证码错误</i>-->
            <input class="button" value="获取验证码" onclick="settime(this,'/Home/Validate/sendCode.html')" name="code" type="button">
        </div>
        <div style="width: 600px;padding-bottom: 30px">
            <button id="submit" style="cursor: pointer">确认提交</button>
            <span id="wait_img" style="display:none;margin-left: 100px;"><img style="width:31px;" src="/Public/default/loading-1.gif"></span>
            <div style="margin-top:0;float: right" id="down">
                <img src="/Public/Home/extend/img/print.jpg" alt="">
                <span style="vertical-align: bottom;display: inline-block;color: #7d7d7d">预览打印</span>
            </div>

        </div>
    </div>
</div>
</form>
<form action="/Home/Index/do_print.html" method="post" name="hld_res" id="hideform">
    <input id="hide_content" name="html" value="
<form class=&quot;form form-horizontal&quot; id=&quot;form-add&quot; enctype=&quot;multipart/form-data&quot; novalidate=&quot;novalidate&quot;>
    <div class=&quot;project_content&quot;>
    <div class=&quot;demand_div&quot;>
        <div class=&quot;demand_div1&quot;>
            <img src=&quot;/Public/Home/extend/img/1.jpg&quot; alt=&quot;&quot;>
            <span>项目申请</span>
        </div>
    </div>
    <div class=&quot;project_div&quot;>
      <div>
          <span>项目申请选择：</span>

          <div style=&quot;margin: 0&quot; class=&quot;c-dropdown js-dropdown&quot;>
              <input name=&quot;p_id&quot; id=&quot;Framework&quot; class=&quot;js-dropdown__input&quot; value=&quot;&quot; type=&quot;hidden&quot;>
              <span class=&quot;c-button c-button--dropdown js-dropdown__current&quot;>请选择</span>
              <ul class=&quot;c-dropdown__list&quot;>
                  <li class=&quot;c-dropdown__item&quot; data-dropdown-value=&quot;6&quot;>道路占用挖掘审核</li><li class=&quot;c-dropdown__item&quot; data-dropdown-value=&quot;5&quot;>道路新增出入口审核</li><li class=&quot;c-dropdown__item&quot; data-dropdown-value=&quot;4&quot;>交通安全设施竣工验收</li><li class=&quot;c-dropdown__item&quot; data-dropdown-value=&quot;3&quot;>交通安全设施设计的审核</li><li class=&quot;c-dropdown__item&quot; data-dropdown-value=&quot;2&quot;>公交站点的设置和审核</li><li class=&quot;c-dropdown__item&quot; data-dropdown-value=&quot;1&quot;>大型项目交通影响评价</li>              </ul>
          </div>

      </div>
        <div>
            <span>附件上传：</span>
            <div style=&quot;margin: 0;&quot; id=&quot;form1&quot; class=&quot;uploader white&quot;>
                <input class=&quot;filename&quot; name=&quot;path&quot; placeholder=&quot;请选择要上传的文件&quot; readonly=&quot;&quot; type=&quot;text&quot;><span style=&quot;display: inline-block;color:#d0d0d0;margin-left: -85px;background:#063892;padding: 10px 10px;border-radius: 10px;margin-top: 5px &quot;>选择上传</span>

                <input name=&quot;upfile&quot; type=&quot;file&quot;>
            </div>

            <span>参考资料下载：<a style=&quot;color: #063892;text-decoration: none&quot; href=&quot;file/授权类特许产品.rar&quot;>许可证（样本）.PDF</a>
            </span>
        </div>
        <div class=&quot;check&quot;>
            <span>材料寄送：</span>
            <lable>
                <i class=&quot;input_style radio_bg radio_bg_check&quot;><input checked=&quot;checked&quot; name=&quot;is_deliver&quot; value=&quot;2&quot; type=&quot;radio&quot;></i>
                否
            </lable>
            <lable>
                <i class=&quot;input_style radio_bg&quot;><input name=&quot;is_deliver&quot; value=&quot;1&quot; type=&quot;radio&quot;></i>
                是
            </lable>
        </div>
        <div class=&quot;text se&quot;>
            <span>快递单号：</span>
            <input placeholder=&quot;请输入快递单号&quot; name=&quot;tracking_no&quot; value=&quot;&quot; type=&quot;tel&quot;>
        </div>
    </div>
    <div class=&quot;project_div1&quot;>
        <div class=&quot;div1&quot;>主审单位</div>
        <div>
            <div>
                <span>部门职务：</span>
                <input placeholder=&quot;请输入部门职务&quot; name=&quot;depart_name&quot; value=&quot;&quot; type=&quot;text&quot;>
            </div>
            <div style=&quot;margin-left: 33px&quot;>
                <span>联系人：</span>
                <input placeholder=&quot;请输入联系人&quot; name=&quot;contact&quot; value=&quot;&quot; type=&quot;text&quot;>
            </div>
            <div>
                <span>电话号码：</span>
                <input placeholder=&quot;请输入电话号码&quot; name=&quot;contact_phone&quot; value=&quot;&quot; type=&quot;tel&quot;>
            </div>
            <div class=&quot;form&quot;>
                <span>邮寄地址：</span>
                <select name=&quot;contact_p&quot; id=&quot;selProvincesContact&quot; onchange=&quot;region.changed(this, 2, 'selCitiesContact')&quot;>
                    <option value=&quot;&quot;>选择省</option>
                    <option value=&quot;110000&quot;>北京</option><option value=&quot;120000&quot;>天津</option><option value=&quot;130000&quot;>河北省</option><option value=&quot;140000&quot;>山西省</option><option value=&quot;150000&quot;>内蒙古自治区</option><option value=&quot;210000&quot;>辽宁省</option><option value=&quot;220000&quot;>吉林省</option><option value=&quot;230000&quot;>黑龙江省</option><option value=&quot;310000&quot;>上海</option><option value=&quot;320000&quot;>江苏省</option><option value=&quot;330000&quot;>浙江省</option><option value=&quot;340000&quot;>安徽省</option><option value=&quot;350000&quot;>福建省</option><option value=&quot;360000&quot;>江西省</option><option value=&quot;370000&quot;>山东省</option><option value=&quot;410000&quot;>河南省</option><option value=&quot;420000&quot;>湖北省</option><option value=&quot;430000&quot;>湖南省</option><option value=&quot;440000&quot;>广东省</option><option value=&quot;450000&quot;>广西壮族自治区</option><option value=&quot;460000&quot;>海南省</option><option value=&quot;500000&quot;>重庆</option><option value=&quot;510000&quot;>四川省</option><option value=&quot;520000&quot;>贵州省</option><option value=&quot;530000&quot;>云南省</option><option value=&quot;540000&quot;>西藏自治区</option><option value=&quot;610000&quot;>陕西省</option><option value=&quot;620000&quot;>甘肃省</option><option value=&quot;630000&quot;>青海省</option><option value=&quot;640000&quot;>宁夏回族自治区</option><option value=&quot;650000&quot;>新疆维吾尔自治区</option><option value=&quot;710000&quot;>台湾</option><option value=&quot;810000&quot;>香港特别行政区</option><option value=&quot;820000&quot;>澳门特别行政区</option><option value=&quot;900000&quot;>钓鱼岛</option>                </select>
                <select name=&quot;contact_c&quot; id=&quot;selCitiesContact&quot; onchange=&quot;region.changed(this, 3, 'selDistrictsContact')&quot;>
                    <option value=&quot;&quot;>选择市</option>
                </select>
                <select name=&quot;contact_d&quot; id=&quot;selDistrictsContact&quot;>
                    <option value=&quot;&quot;>选择区</option>
                </select>
                <input style=&quot;margin-left: 30px&quot; name=&quot;contact_address&quot; placeholder=&quot;具体收件地址&quot; type=&quot;text&quot;>
            </div>
        </div>
    </div>
    <div class=&quot;project_div2&quot;>
        <div class=&quot;check1 &quot;>
            <span>现场勘测:</span>
            <lable>
                <i class=&quot;input_style radio_bg radio_bg_check&quot;><input name=&quot;need_survey&quot; value=&quot;2&quot; checked=&quot;&quot; type=&quot;radio&quot;></i>
                不需要
            </lable>
            <lable>
                <i class=&quot;input_style radio_bg&quot;><input name=&quot;need_survey&quot; value=&quot;1&quot; type=&quot;radio&quot;></i>
                需要
            </lable>
        </div>
        <div class=&quot;text1 se&quot;>
            <div style=&quot;margin-left:30px &quot;>
                <span>时间:</span>
                <input placeholder=&quot;请选择时间&quot; value=&quot;&quot; name=&quot;survey_start_time&quot; onfocus=&quot;WdatePicker({ minDate:'%y-%M-%d',dateFmt:'yyyy-MM-dd' })&quot; id=&quot;logmin&quot; class=&quot; Wdate&quot; style=&quot;width:160px;&quot; type=&quot;text&quot;>
                -<input placeholder=&quot;请选择时间&quot; value=&quot;&quot; name=&quot;survey_end_time&quot; onfocus=&quot;WdatePicker({ minDate:'#F{$dp.$D(\'logmin\')}',dateFmt:'yyyy-MM-dd' })&quot; id=&quot;logmax&quot; class=&quot; Wdate&quot; style=&quot;width:160px;&quot; type=&quot;text&quot;>
            </div>
            <div style=&quot;margin-left:30px &quot;>
                <span>地点:</span>
                <select name=&quot;survey_p&quot; id=&quot;selProvincesSurvey&quot; onchange=&quot;region.changed(this, 2, 'selCitiesSurvey')&quot;>
                    <option value=&quot;&quot;>选择省</option>
                    <option value=&quot;110000&quot;>北京</option><option value=&quot;120000&quot;>天津</option><option value=&quot;130000&quot;>河北省</option><option value=&quot;140000&quot;>山西省</option><option value=&quot;150000&quot;>内蒙古自治区</option><option value=&quot;210000&quot;>辽宁省</option><option value=&quot;220000&quot;>吉林省</option><option value=&quot;230000&quot;>黑龙江省</option><option value=&quot;310000&quot;>上海</option><option value=&quot;320000&quot;>江苏省</option><option value=&quot;330000&quot;>浙江省</option><option value=&quot;340000&quot;>安徽省</option><option value=&quot;350000&quot;>福建省</option><option value=&quot;360000&quot;>江西省</option><option value=&quot;370000&quot;>山东省</option><option value=&quot;410000&quot;>河南省</option><option value=&quot;420000&quot;>湖北省</option><option value=&quot;430000&quot;>湖南省</option><option value=&quot;440000&quot;>广东省</option><option value=&quot;450000&quot;>广西壮族自治区</option><option value=&quot;460000&quot;>海南省</option><option value=&quot;500000&quot;>重庆</option><option value=&quot;510000&quot;>四川省</option><option value=&quot;520000&quot;>贵州省</option><option value=&quot;530000&quot;>云南省</option><option value=&quot;540000&quot;>西藏自治区</option><option value=&quot;610000&quot;>陕西省</option><option value=&quot;620000&quot;>甘肃省</option><option value=&quot;630000&quot;>青海省</option><option value=&quot;640000&quot;>宁夏回族自治区</option><option value=&quot;650000&quot;>新疆维吾尔自治区</option><option value=&quot;710000&quot;>台湾</option><option value=&quot;810000&quot;>香港特别行政区</option><option value=&quot;820000&quot;>澳门特别行政区</option><option value=&quot;900000&quot;>钓鱼岛</option>                </select>
                <select name=&quot;survey_c&quot; id=&quot;selCitiesSurvey&quot; onchange=&quot;region.changed(this, 3, 'selDistrictsSurvey')&quot;>
                    <option value=&quot;&quot;>选择市</option>
                </select>
                <select name=&quot;survey_d&quot; id=&quot;selDistrictsSurvey&quot;>
                    <option value=&quot;&quot;>选择区</option>
                </select>
                <input style=&quot;margin-left: 30px&quot; name=&quot;survey_address&quot; placeholder=&quot;具体地址&quot; type=&quot;text&quot;>
            </div>
            <div style=&quot;margin-left:15px &quot;>
                <span>联系人:</span>
                <input placeholder=&quot;请输入联系人&quot; name=&quot;survey_contact&quot; type=&quot;text&quot;>
            </div>
            <div>
                <span>注意事项:</span>
                <input name=&quot;survey_attention&quot; placeholder=&quot;请输入注意事项&quot; type=&quot;text&quot;>
            </div>
        </div>

        <div class=&quot;check2&quot;>
            <span>审批表格<br>是否寄送:</span>
            <lable>
                <i class=&quot;input_style radio_bg radio_bg_check&quot;><input name=&quot;need_deliver&quot; value=&quot;2&quot; checked=&quot;&quot; type=&quot;radio&quot;></i>
                否
            </lable>
            <lable>
                <i class=&quot;input_style radio_bg&quot;><input name=&quot;need_deliver&quot; value=&quot;1&quot; type=&quot;radio&quot;></i>
                是
            </lable>
        </div>
        <div class=&quot;text se&quot;>
            <div style=&quot;margin-left: 15px&quot;>
                <span>收件人:</span>
                <input placeholder=&quot;请输入收件人姓名 &quot; name=&quot;receiver_name&quot; type=&quot;text&quot;>
            </div>
            <div>
                <span>收件地址:</span>
                <select name=&quot;receiver_p&quot; id=&quot;selProvincesReceiver&quot; onchange=&quot;region.changed(this, 2, 'selCitiesReceiver')&quot;>
                    <option value=&quot;&quot;>选择省</option>
                    <option value=&quot;110000&quot;>北京</option><option value=&quot;120000&quot;>天津</option><option value=&quot;130000&quot;>河北省</option><option value=&quot;140000&quot;>山西省</option><option value=&quot;150000&quot;>内蒙古自治区</option><option value=&quot;210000&quot;>辽宁省</option><option value=&quot;220000&quot;>吉林省</option><option value=&quot;230000&quot;>黑龙江省</option><option value=&quot;310000&quot;>上海</option><option value=&quot;320000&quot;>江苏省</option><option value=&quot;330000&quot;>浙江省</option><option value=&quot;340000&quot;>安徽省</option><option value=&quot;350000&quot;>福建省</option><option value=&quot;360000&quot;>江西省</option><option value=&quot;370000&quot;>山东省</option><option value=&quot;410000&quot;>河南省</option><option value=&quot;420000&quot;>湖北省</option><option value=&quot;430000&quot;>湖南省</option><option value=&quot;440000&quot;>广东省</option><option value=&quot;450000&quot;>广西壮族自治区</option><option value=&quot;460000&quot;>海南省</option><option value=&quot;500000&quot;>重庆</option><option value=&quot;510000&quot;>四川省</option><option value=&quot;520000&quot;>贵州省</option><option value=&quot;530000&quot;>云南省</option><option value=&quot;540000&quot;>西藏自治区</option><option value=&quot;610000&quot;>陕西省</option><option value=&quot;620000&quot;>甘肃省</option><option value=&quot;630000&quot;>青海省</option><option value=&quot;640000&quot;>宁夏回族自治区</option><option value=&quot;650000&quot;>新疆维吾尔自治区</option><option value=&quot;710000&quot;>台湾</option><option value=&quot;810000&quot;>香港特别行政区</option><option value=&quot;820000&quot;>澳门特别行政区</option><option value=&quot;900000&quot;>钓鱼岛</option>                </select>
                <select name=&quot;receiver_c&quot; id=&quot;selCitiesReceiver&quot; onchange=&quot;region.changed(this, 3, 'selDistrictsReceiver')&quot;>
                    <option value=&quot;&quot;>选择市</option>
                </select>
                <select name=&quot;receiver_d&quot; id=&quot;selDistrictsReceiver&quot;>
                    <option value=&quot;&quot;>选择区</option>
                </select>
                <input style=&quot;margin-left: 30px&quot; placeholder=&quot;具体收件地址&quot; name=&quot;receiver_address&quot; type=&quot;text&quot;>

            </div>
            <div>
                <span>联系方式:</span>
                <input placeholder=&quot;请输入联系方式&quot; value=&quot;&quot; name=&quot;receiver_phone&quot; type=&quot;tel&quot;>
            </div>
        </div>

        <div style=&quot;margin-left: 15px&quot;>
            <span>申请人:</span>
            <input placeholder=&quot;请输入申请人姓名&quot; value=&quot;&quot; name=&quot;submitter&quot; type=&quot;text&quot;>
        </div>
        <div>
            <span>申请单位:</span>
            <input placeholder=&quot;请输入申请单位全称&quot; value=&quot;&quot; name=&quot;submitter_company&quot; type=&quot;text&quot;>
        </div>
        <div>
            <span>手机号码:</span>
            <input placeholder=&quot;请输入手机号码&quot; value=&quot;&quot; name=&quot;validate_phone&quot; id=&quot;validate_phone&quot; type=&quot;text&quot;>
        </div>
        <div>
            <span>验证码：</span>
            <input placeholder=&quot;请输入验证码&quot; name=&quot;validate_code&quot; type=&quot;text&quot;>
            <!--<i style=&quot;color: red&quot;>*验证码错误</i>-->
            <input class=&quot;button&quot; value=&quot;获取验证码&quot; onclick=&quot;settime(this,'/Home/Validate/sendCode.html')&quot; name=&quot;code&quot; type=&quot;button&quot;>
        </div>
        <div style=&quot;width: 600px;padding-bottom: 30px&quot;>
            <button id=&quot;submit&quot; style=&quot;cursor: pointer&quot;>确认提交</button>
            <span id=&quot;wait_img&quot; style=&quot;display:none;margin-left: 100px;&quot;><img style=&quot;width:31px;&quot; src=&quot;/Public/default/loading-1.gif&quot;></span>
            <div style=&quot;margin-top:0;float: right&quot; id=&quot;down&quot;>
                <img src=&quot;/Public/Home/extend/img/print.jpg&quot; alt=&quot;&quot;>
                <span style=&quot;vertical-align: bottom;display: inline-block;color: #7d7d7d&quot;>预览打印</span>
            </div>

        </div>
    </div>
</div>
</form>
<form action=&quot;/Home/Index/do_print.html&quot; method=&quot;post&quot; name=&quot;hld_res&quot; id=&quot;hideform&quot;>
    <input id=&quot;hide_content&quot; name=&quot;html&quot; type=&quot;hidden&quot;>
</form>
" type="hidden">
</form>
</body></html>